Fixation Of Proximal Femoral Fractures Research Articles

Factors associated with increased radiation exposure in the fixation of proximal femoral fractures.

When using radiation intraoperatively, a surgeon should aim to keep the radiation dose as low as is reasonably achievable to obtain the therapeutic goal. We aimed to investigate factors associated with increased radiation exposure in fixation of proximal femur fractures. We assessed 369 neck of femur fractures over a 1-year period in a district general hospital. All hip fracture subtypes that had undergone surgical fixation were included. We assessed the relationship between type of fracture, implants used and surgeon level of experience with the dose-area product (DAP; cGy/cm2) and screening time (dS). We also looked at the quality of reduction and fixation and its effect on the radiation exposure. A total of 184 patients were included in our analysis; 185 patients who were treated with hip arthroplasty were excluded. There was a significant association between higher DAP and fracture subtype (p = 0.001), fracture complexity (p < 0.001), if an additional implant was used (p = 0.001), if fixation was satisfactory (p = 0.002) and operative time (p < 0.001). DAP was higher with a proximal femoral nail than with a dynamic hip screw, especially when a long nail was used. There was some evidence of an association between the surgeon's level of experience and DAP exposure, although this was not statistically significant (p = 0.069). Increased radiation in proximal femur fractures is seen in the fixation of complex fractures, some subtypes, with certain types of implants used and if an additional implant was required. Surgeon seniority did not result in less radiation exposure, which is in contrast to other published studies.

Techniques for abductor reattachment in proximal femoral replacement for non-oncological reconstructions: a narrative review.

Proximal femoral replacement due to revision hip arthroplasty or catastrophic proximal femur fracture fixation failures with considerable proximal femur bone loss can lead to a substantial loss of function of the soft tissue around the hip and the abductor muscles in particular. Surgical techniques of gluteus medius repair and/or abductor mechanism reattachment/reconstruction are widely debated in the literature, but it is quite rarely dealt with in the context of megaprosthesis and femoral reconstruction, particularly in non-oncologic patients. The aim of this study is to present a narrative review of the literature on techniques for abductor reattachment in proximal femoral replacement for non-oncological reconstructions. MEDLINE, Embase, and Cochrane databases were searched by two researchers independently from inception until February 1st, 2023 (923 for MEDLINE and 963 for Embase; Cochrane is a composite of multiple databases and thus does not report a standard inception date). Articles examining proximal femoral reconstruction with megaprosthesis or allograft prosthesis were included. Studies concerning cadaver and oncologic patients were excluded. If the researchers failed to find an agreement on whether to include a study, the senior researcher would make a final decision in such cases. Data were extracted and stored, and qualitative synthesis was performed. A total of 1,157 articles from MEDLINE, 11,187 articles from Embase, and 0 articles from Cochrane were identified. Of 12,344 articles, the structured screening process revealed 10 eligible trials. Four different types of abductor musculature reconstruction/reinsertion were identified. Multiple and complex revision hip arthroplasties as well as multiple surgical procedures for proximal femur fracture fixations failures may have a great impact on proximal femur bone stock condition and soft tissue preservation requiring the use of a proximal femur megaprosthesis. In such cases, the abductor mechanism reconstruction and/or reattachment is achievable with different techniques that can be resumed in four different groups: direct suture to the prosthesis, trochanteric sleeve osteotomy, muscle-to-muscle suture, and synthetic tube augmentation suture.

Outcomes of conversion total hip arthroplasty for failed fixation of intertrochanteric fractures with monoblock distal-loading reconstruction stem.

The aim of our study was to analyze the clinical and radiological outcomes of conversion total hip arthroplasty (THA) for failed fixation of proximal femur fractures with monoblock grit-blasted titanium reconstruction stem (Wagner self-locking stem, Zimmer). Thirty-nine patients were included in this retrospective analysis undergoing conversion THA for failed cephalomedullary nail or dynamic hip screw fixation for intertrochanteric fractures from January 2017 to January 2022. The clinical evaluation was done using Harris hip score. The radiological outcomes measured were subsidence, level of osteointegration, stem-canal fill ratio and heterotopic bone formation. The complications were noted postoperatively and during the follow-up. The mean follow-up at the end of the study was 27.8months (range, 14-72months). There was a significant improvement in the Harris hip score over serial follow-ups (p < 0.001), but after 2years, there was no statistically significant difference (p = 0.46). According to Engh's criteria, stable ingrowth was noted in 35 stems, fibrous stable ingrowth was noted in 4 stems and no patients had progressive subsidence and unstable stem. The mean stem-canal fill percentages were 91.8 ± 5.4% at the mid-stem and 80.3 ± 11.5% at the stem tip. Heterotopic ossification Brooker grade 2 was noted in 8 patients, and no patients had grade 3 or 4 heterotopic ossification. There were 7 (17.9%) intraoperative periprosthetic fractures, and greater trochanteric avulsion was noted in 2 patients in the follow-up. Conversion THA using monoblock tapered distal loading stems bypasses the calcar deficiency and gives stable fixation in failed fixation of intertrochanteric fractures. It gives good radiological outcome and significant improvement in the clinical outcomes compared to the preoperative disability. However, caution should be noted for risk of intraoperative periprosthetic fractures in this subgroup of patients.

Outcomes of total hip arthroplasty using dual mobility cups following failed internal fixation of proximal femoral fractures at a mean follow-up of 6years.

Performing total hip arthroplasty (THA) after failed internal fixation of proximal femoral fractures (PFF) is known to be associated with high rates of complications. Dual mobility cups (DMC) are known to lower dislocation events in high-risk patients. Very few reports investigated the outcomes of THA using DMC following failure of internal fixation for PFF. This is a retrospective monocentric continuous study of 31 patients who underwent THA with DMC after failed internal fixation of PFF. The clinical assessment was based on the modified Harris hip score (mHHS) at the last follow-up. The complication rates and radiological analyses were recorded. The mean follow-up period was 5.96±4.2years. At the last follow-up, the mean mHHS was 92.9±9.1 with 71% of the patients describing their operated hip as a forgotten hip. No dislocation or aseptic loosening events were noted. One patient developed a septic loosening of the implant. No significant radiological changes were recorded. Sixteen stems (51.6%) were placed in a neutral position, 13 (42%) in valgus (2.74±1.72°), and 2 (6.4%) in varus (6.94±2.02°). This study emphasizes the advantage of using DMC following failed internal fixation of PFF in reducing dislocation and complication events in this high-risk population.

Trochanteric entry awl for cephalomedullary nailing of femur

Proximal femur fracture fixation with cephalomedullary nails are done routinely nowadays. It needs a precise entry site for passing nail after proper near anatomical reduction. More over comminution of fracture obesity add up more difficulty for fixation. Awls are used to make a entry in proximal femur in trochanteric pyriformis fossa. The available awls provided by different implant companies vary in size and shape and length, this causes difficulty in having a proper entry especially in obese patients wherein the pendulous abdomen wall and flanks obstruct the awl handle. So the author has designed solid as well as cannulated Trochanteric entry awl for ease of making entry in proximal femur thus making the surgery easy.

Mechanical outcomes of the TFNA, InterTAN and IMHS intramedullary nailing systems for the fixation of proximal femur fractures

IntroductionHip fractures have become a major public health priority due to their increasing incidence. Intramedullary (IM) nailing has gained popularity as a surgical technique for managing these fractures. However, comparative studies with extramedullary devices indicate potentially increased mechanical complications associated with IM nailing. Specifically, there have been recent reports of early implant fracture associated with the TFNA system. This study compares the rate of mechanical complications between 3 implants. Secondarily, we analysed the factors associated with implant fracture and all other mechanical complications. MethodsThis retrospective study included 803 IM nails performed between 2008–2021 for the fixation of proximal femur fractures at a level 1 trauma centre. We recorded patient demographics, AO fracture classification, implant specification and intra-operative parameters such as tip-apex distance, Cleveland index, reduction quality, presence of medial calcar integrity, neck-shaft angle. The outcomes analysed included implant fracture, lag screw cut-out, >10 mm backing out, autodynamisation, periprosthetic fracture, non-union at 6 months and time to revision surgery. ResultsThe overall implant fracture rate was 3.1 % (25/803), with no statistically significant difference between the three devices (p = 0.51). The TFNA group included 183 patients with a median follow-up of 1.6 years. The TFNA fracture rate was 2.2 % (4/183) which occurred at 207 +/- 16.66 days post-operatively. The rate of all mechanical complications was 4.9 % in the TFNA group, 12.9 % in the InterTAN group and 17 % in the IMHS group. Non-union (p < 0.001) and increasing lag screw length (p < 0.02) were identified as risk factors for implant fracture and other mechanical complications. The reverse oblique fracture pattern (AO 31 A3.1) was associated with mechanical complications only (p < 0.01). The cumulative survival rates without revision for the TFNA, InterTAN, IMHS groups were 97.8 %, 95.5 % and 87.9 % respectively at 2.5 years. DiscussionThe rates of implant fracture were comparable between the three nailing systems. The TFNA provides effective fixation for proximal femur fractures using a traditional screw without cement augmentation. The TFNA was associated with an overall reduction in mechanical complications compared to the InterTAN and IMHS. Previously reported mechanical complications associated with IM Nails may relate to older device designs.

Early Failure of Locking Compression Plates in Pediatric Proximal Femoral Fracture

Background: Although proximal femoral locking compression plates (PF-LCP) have been used with increasing frequency in the fixation of proximal femoral fractures in the pediatric population, there is a lack of literature regarding their use. The purpose of this study was to examine the failure rates of PF-LCP fixation in comparison to other accepted fixation methods within a pediatric population.Methods: Retrospective review identified consecutive children treated for proximal femoral fractures from September 2008 to February 2019, who had a minimum follow-up of 12 weeks. Patient charts and radiographs were reviewed, and demographic information was compiled. In the case of failures, timing and method of failure were documented.Results: Sixty-four proximal femoral fractures (61 children) were studied. The average age at the time of presentation was 10.4 years. Twenty-six fractures were treated with PF-LCPs and 38 with other fixation methods (compression hip screws, rigid locked intramedullary nailing, cannulated screws, or a combination of hip screw side plate and intramedullary nailing). Failure occurred in four of the 26 fractures treated with locking compression plating (15.4%) compared to none of the 38 treated with other fixation types (p<0.05).Conclusions: This study demonstrates a higher rate of failure in proximal femoral fractures, particularly basicervical and transcervical femoral neck fractures, treated with locking compression plates (12.9%) compared to 0% other fixation methods (no failures). As a result of this study, we no longer use locked plating systems for pediatric femoral neck fractures at our institution.Level of Evidence: Level III Key Concepts•Proximal femoral fractures account for less than 1% of all fractures in children.•Locking compression plates are being more frequently used in pediatric proximal femoral fractures.•Outcome studies are limited because of the low incidence of these fractures and relative recent introduction of this fixation method.•Proximal femoral compression locking plates had a higher rate of early mechanical failure than other fixation modalities in this study.•The increased risk of failure with proximal femoral compression locking plates should be considered before opting for these implants.

Clockwise torque results in higher reoperation rates in left-sided femur fractures

PurposeEffects of clockwise torque rotation onto proximal femoral fracture fixation have been subject of ongoing debate: fixated right-sided trochanteric fractures seem more rotationally stable than left-sided fractures in the biomechanical setting, but this theoretical advantage has not been demonstrated in the clinical setting to date. The purpose of this study was to identify a difference in early reoperation rate between patients undergoing surgery for left- versus right-sided proximal femur fractures using cephalomedullary nailing (CMN). Materials and methodsThe American College of Surgeons National Surgical Quality Improvement Program was queried from 2016-2019 to identify patients aged 50 years and older undergoing CMN for a proximal femoral fracture. The primary outcome was any unplanned reoperation within 30 days following surgery. The difference was calculated using a Chi-square test, and observed power calculated using post-hoc power analysis. ResultsIn total, of 20,122 patients undergoing CMN for proximal femoral fracture management, 1.8% (n=371) had to undergo an unplanned reoperation within 30 days after surgery. Overall, 208 (2.0%) were left-sided and 163 (1.7%) right-sided fractures (p=0.052, risk ratio [RR] 1.22, 95% confidence interval [CI] 1.00–1.50), odds ratio [OR] 1.23 (95%CI 1.00–1.51), power 49.2% (α=0.05). ConclusionThis study shows a higher risk of reoperation for left-sided compared to right-sided proximal femur fractures after CMN in a large sample size. Although results may be underpowered and statistically insignificant, this finding might substantiate the hypothesis that clockwise rotation during implant insertion and (postoperative) weightbearing may lead to higher reoperation rates. Level of evidenceTherapeutic level II.

EARLY BISPHOSPHONATE THERAPY POST PROXIMAL FEMORAL FIXATION DOES NOT IMPACT FRACTURE HEALING

There is conjecture on the optimal timing to administer bisphosphonate therapy following operative fixation of low- trauma hip fractures. Factors include recommendations for early opportunistic commencement of osteoporosis treatment, and clinician concern regarding the effect of bisphosphonates on fracture healing. We performed a systematic review and meta-analysis to determine if early administration of bisphosphonate therapy within the first month post-operatively following proximal femur fracture fixation is associated with delay in fracture healing or rates of delayed or non-union.We included randomised controlled trials examining fracture healing and union rates in adults with proximal femoral fractures undergoing osteosynthesis fixation methods and administered bisphosphonates within one month of operation with a control group. Data was pooled in meta-analyses where possible. The Cochrane Risk of Bias Tool and the GRADE approach were used to assess validity.For the outcome of time to fracture union, meta-analysis of three studies (n= 233) found evidence for earlier average time to union for patients receiving early bisphosphonate intervention (MD = −1.06 weeks, 95% CI −2.01 – −0.12, I2= 8%). There was no evidence from two included studies comprising 718 patients of any difference in rates of delayed union (RR 0.61, 95% CI 0.25–1.46). Meta-analyses did not demonstrate a difference in outcomes of mortality, function, or pain.We provide low-level evidence that there is no reduction in time to healing or delay in bony union for patients receiving bisphosphonates within one month of proximal femur fixation.

High Percentage of Complications and Re-Operations Following Dynamic Locking Plate Fixation with the Targon® FN for Intracapsular Proximal Femoral Fractures: An Analysis of Risk Factors.

The ideal surgical treatment of femoral neck fractures remains controversial. When treating these fractures with internal fixation, many fixation constructs exist. The primary aim of this study was to evaluate the incidence and specific risk factors associated with complication and re-operation following fixation of intracapsular proximal femoral fractures using the Targon-FN system (B.Braun Melsungen AG). A secondary aim was to identify if lateral prominence of the implant relative to the lateral border of the vastus ridge was a specific risk factor for elective plate removal. Methodically, a retrospective case series was conducted of all consecutive adult patients treated at a single level 1 trauma center in Switzerland for an intracapsular proximal femoral fracture with the Targon-FN. Demographic data were collected. Patients with a follow-up of less than three months were excluded. Complications as well as plate position were recorded. Statistical analysis to identify specific risk factors for re-operation and complications was performed. In result, a total of 72 cases with intracapsular femoral neck fractures were treated with the Targon-FN locking plate system between 2010 and 2017. Thirty-four patients (47.2%) experienced one or more complications. The most common complication was mechanical irritation of the iliotibial band (ITB) (23.6%, n = 17). Complications included intraarticular screw perforation (6.9%, n = 5), avascular necrosis (5.6%, n = 4), non-union (5.6%, n = 4) among others. In total, 46 re-operations were required. Younger age, fracture displacement and time to postoperative weight bearing were identified as risk factors for re-operation. In conclusion, intracapsular femoral neck fractures treated with the Targon-FN system resulted in a high rate of post-operative complication and re-operation. Statistical analysis revealed patient age, fracture displacement, time to postoperative full weight bearing were risk factors for re-operation. The main limitation is the limited number of cases and a short follow-up of less than 12 months in a subgroup of our patients.

Anesthetic Management of a Patient with Severe Systolic Dysfunction Posted for Proximal Femur Fracture Fixation- A Case Report

Anesthetic Management of a Patient with Severe Systolic Dysfunction Posted for Proximal Femur Fracture Fixation- A Case Report

Measurement of Tip Apex Distance and its Relation with Cut-Out After Fixation of Proximal Femoral Fractures with Dynamic Hip Screw or Proximal Femoral Nail A Retrospective Longitudinal Analysis of 106 Patients

Measurement of Tip Apex Distance and its Relation with Cut-Out After Fixation of Proximal Femoral Fractures with Dynamic Hip Screw or Proximal Femoral Nail A Retrospective Longitudinal Analysis of 106 Patients

Geriatric Distal Femur Fracture Management Protocols: A Review and Evidence-based Template

Objectives: Provide a framework for the development of a “Code Femur” protocol for geriatric distal femur fractures.&#x0D; Design: Literature Review and Evidence Based Note Templates&#x0D; Intervention: Distal Femur Fracture Fixation and Medical Management&#x0D; Main Outcome Measurement: Post operative Mortality&#x0D; Results: Geriatric distal femur fractures are rising in number among osteoporotic fractures in the growing elderly population. Current hip fracture literature recommends fixation of proximal femur fractures in 24-48 hours to reduce mortality and the literature surrounding distal femur fractures in this population in trending in this direction as well. The goals of distal femur fracture surgery are early mobilization and fracture stabilization in addition to managing the multiple medical co-morbidities that these patients may have. This review discusses the treatment options available for geriatric distal femur fractures that allow for early mobilization and examines the benefits of early operative care.&#x0D; Conclusion: Geriatric Distal Femur Fractures present similar challenges to management as the geriatric hip fracture and a proper understanding of medical co-management and early appropriate surgery through the development of a distal femur fracture program similar to hip benefits warrants consideration.&#x0D; Level of Evidence: Level IV, Systematic Review&#x0D; Keywords: Code Femur, Geriatric, Distal Femur Fracture, Post-operative Mortality, Co-Morbidity

Salvage hip replacement after cut-out failure of cephalomedullary nail fixation for proximal femur fractures: a case series describing the technique and results.

Cut-out failure following proximal femoral fracture fixation is a compromising complication warranting surgical treatment. We describe 24 patients with cut-out failure after cephalomedullary nail fixation managed with salvage hip replacement. Twenty-four consecutive patients who had sustained a proximal femoral fracture from December 2009 to December 2019, were managed with cephalomedullary nail fixation and experienced a cut-out failure were reviewed retrospectively. Data on demographics, comorbidities, injury characteristics, treatment, and post-operative course were analysed. Among 2802 proximal femoral fractures assessed, 28 fixations failed due to cut-out, with 24/28 patients subsequently undergoing salvage hip replacement. Intertrochanteric fractures (66.7%) managed with short nails predominated (79.2%). The median tip-to-apex distance (TAD) was 19mm, but only two fractures had a good quality of reduction. Inverse correlations were identified between patient age and the time from fixation to cut-out (r = - 0.57; p = 0.02), and between the time of nailing to failure among patients with a greater TAD (r = - 0.43; p = 0.04). Most patients were managed via cemented hemiarthroplasty (66.7%). Surgical time was longer for total hip replacements (175.4 vs. 136.8min; p < 0.01), but no bleeding or blood transfusion requirement differences were found. Two patients had orthopaedic complications, and three patients died within the first follow-up year. In our series, 1% of the proximal femoral fractures managed with a cephalomedullary nail failed due to cut-out. Salvage hip replacement appeared to be a relatively safe and reliable procedure for managing this challenging complication in patients who typically are elderly and physically frail.

Implant survival of cemented arthroplasty following failed fixation of proximal femoral fractures in patients aged 30–60 years: a retrospective study with a median follow-up of 10 years

BackgroundGiven the unremitting growth in the volume of failed fixations of proximal femoral fractures (PFFs) in recent years, it is predictable that total hip replacements (THRs) will be the preferred surgical procedure. The long-term survival of cemented THR (CTHR) revisions remains controversial in patients aged 30–60 years. The goal of this retrospective review was to evaluate the 10-year survival of CTHRs following prior failed primary fixations of PFFs in patients aged 30–60 years.MethodsWe retrospectively identified CTHR revisions implemented at four medical centres during 2008–2017 for a failed primary fixation of PFFs in consecutive patients aged 30–60 years. The primary endpoint was implant survival calculated using the Kaplan–Meier method with 95% confidence intervals (CIs); secondary endpoints included functional scores assessed by Harris hip scores (HHS) and main revision-related orthopaedic complications. Follow-up was executed at 1, 2, 3, and 8 years following revision and then at 1-year intervals until the revision, death, or study deadline, whichever occurred first.ResultsIn total, 120 patients (120 hips) who met the eligibility criteria were eligible for follow-up. The median follow-up was 10.2 years (range, 8–12 years). Kaplan–Meier survivorship showed that implant survival with revision for any reason as the endpoint was 95% at 5 years (CI: 93–97%), 89% at 8 years (CI: 86–92%), and 86% at 10 years (CI: 83–89%). Patients treated with three hollow screws had better revision-free survival than patients treated with proximal femoral nail antirotation (PFNA), dynamic hip screw (DHS) or titanium plate plus screws (three p < 0.05). Functional scores were apt to decrease gradually, and at the final follow-up, the mean HHS was 76.9 (range, 67.4–86.4). The overall rate of main revision-related orthopaedic complications was 18.3% (22/120).ConclusionCTHR implemented following prior failed primary fixations of PFFs tends to afford an acceptable 10-year survival, along with advantageous HHS and a low rate of main revision-related orthopaedic complications, which may support an inclination to follow the utilisation of CTHRs, especially in revision settings for intracapsular fractures.

Reoperation rates after proximal femur fracture fixation with single and dual screw femoral nails: a systematic review and meta-analysis

PurposeThe purpose of this study was to investigate differences in aseptic reoperation rates between single or dual lag screw femoral nails,in the treatment of intertrochanteric fractures (ITF) in elderly patients.MethodsElectronic databases were searched for RCTs and prospective cohort studies treating elderly ITF patients with a single or dual screw femoral nails. Data for aseptic reoperation rates between single screw, dual separated screw and dual integrated screw devices were pooled using a random-effects meta-analysis with 95% CIs. Pooled proportions were compared using a N-1 chi-squared test. Complications contributing to aseptic reoperation rates were extracted, and the contribution of cut-out and periprosthetic fracture as a proportion of reoperations was analysed using a negative binomial regression model.ResultsForty-two (n = 42) studies were evaluated, including 2795 patients treated with a single screw device, 1309 patients treated with a dual separated screw device and 303 patients treated with a dual integrated screw device. There was no significant difference in aseptic reoperation rates between single and dual lag screw femoral nails of both separated and integrated lag screw designs. Moreover, complications of cut-out and periprosthetic fracture as a proportion of reoperations did not differ significantly between devices.ConclusionThe current evidence showed that aseptic reoperation rates were not significantly different between single and dual screw nails of a separated lag screw design. For dual integrated screw devices, due to insufficient evidence available, further high quality RCTs are required to allow for decisive comparisons with these newer devices.

Early bisphosphonate therapy post proximal femoral fracture fixation does not impact fracture healing: a systematic review and meta-analysis.

There is conjecture on the optimal timing to administer bisphosphonate therapy following operative fixation of low-trauma hip fractures. Factors include recommendations for early opportunistic commencement of osteoporosis treatment, and clinician concern regarding the effect of bisphosphonates on fracture healing. We performed a systematic review and meta-analysis to determine if early administration of bisphosphonate therapy within the first month post-operatively following proximal femur fracture fixation is associated with delay in fracture healing or rates of delayed or non-union. We included randomized controlled trials examining fracture healing and union rates in adults with proximal femoral fractures undergoing osteosynthesis fixation methods and administered bisphosphonates within 1 month of operation with a control group. Data were pooled in meta-analyses where possible. The Cochrane Risk of Bias Tool and the GRADE approach were used to assess validity. For the outcome of time to fracture union, meta-analysis of three studies (n=233) found evidence for earlier average time to union for patients receiving early bisphosphonate intervention (MD=-1.06 weeks, 95% CI -2.01--0.12, I2 = 8%). There was no evidence from two included studies comprising 718 patients of any difference in rates of delayed union (RR 0.61, 95% CI 0.25-1.46). Meta-analyses did not demonstrate a difference in outcomes of mortality, function or pain. We provide low-level evidence that there is no reduction in time to healing or delay in bony union for patients receiving bisphosphonates within 1 month of proximal femur fixation.

Comparative study to assess the functional outcome in management of inter-trochanteric fractures by proximal femoral nail versus proximal femoral nail anti-rotation

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Proximal femoral fractures are one of the most common fractures occurring in elderly due to osteoporosis and increase in life expectancy. The management of these fractures poses a serious challenge in terms of obtaining a stable fixation and a good post-operative outcome. In this study, we compare two intramedullary devices: Proximal femoral nail (PFN) and proximal femoral nail anti-rotation (PFN-A), used commonly for the fixation of proximal femoral fractures.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Patients presenting with inter-trochanteric fractures were included and randomly allocated to two groups for treatment with either PFN or PFN-A. Pre-operative radiographs of normal side were used to grade osteoporosis by Singh’s index. Post-operative radiographs were used to assess the tip-apex distance and quality of reduction. Functional outcome was compared on the basis of Harris hip score at final follow-up. Patients were followed up at an interval of 1, 3 and 6 months respectively.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; The study included 30 patients with 15 patients in each group. The duration of surgery and blood loss was significantly less in PFN-A group as compared to PFN. Functional outcome as assessed by Harris hip score was similar in both the groups. Implant related complications, though less in PFN-A group, had statistically insignificant difference.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; It can be safely concluded that, in spite of no differences in functional outcome between the two groups, a shorter duration of surgery and less blood loss would still make PFN-A a better choice in such patients, especially the elderly and co-morbid/compromised patients.&lt;/p&gt;

Medical Management of Common Comorbidities in Elderly Patients with Proximal Femur Fractures

Objectives: Provide a framework for the medical treatment of patients with proximal femur fractures. Design: Literature review and evidence based note template. Intervention: Medical management of patient undergoing operative fixation of proximal femur fracture. Main outcome measurement: Perioperative morbidity. Results and conclusions: Proximal femur fractures are common orthopaedic injuries in the geriatric population and present with morbidity and portend mortality. The current evidence suggests that most patients should be surgically managed 24-48 hours from injury in accordance with patient preferences and medical risk stratification. Doing so is likely to improve postoperative outcomes and save both patients and hospital systems financial resources. After proper history and physical examination, imaging with plain radiographs is recommended, with MRI indicated in occult fractures. There are numerous cardiovascular, cognitive, and endocrinologic comorbidities that may delay or impact surgical treatment of hip fracture patients. This review discusses informed consent, cardiovascular implantable electronic devices, anticoagulation, preoperative cardiovascular evaluation, anemia, congenital heart disease, cerebrovascular accident, hyponatremia, diabetes mellitus, end-stage renal disease, osteoporosis, COVID-19 and chronic obstructive pulmonary disease, and history of bariatric surgery. A proper understanding of how these conditions affect hip fracture patients may help orthopaedic surgeons to expedite surgery safely and effectively and may also serve as a framework in the management of other fragility fractures in patients with comorbidities. Level of Evidence: IV, systematic review Keywords: Hip Fracture, Medical co-management, Geriatrics, Fragility fracture, Osteoporosis, Comorbidity, Comorbidity management, Anesthesia, Perioperative morbidity, Cardiovascular, Cerebrovascular, Renal disease, Surgical timing. (J Ortho Business 2022; Volume 2, Issue 2

Tips and tricks to avoid implant failure in proximal femur fractures treated with cephalomedullary nails: a review of the literature.

Objective:To describe the surgical aspects potentially contributing to hardware failure of cephalomedullary nails.Data Sources:A search of the Embase, PubMed (MEDLINE), Web of Science, and the Cochrane library for reports of hardware failures after intramedullary fixation of proximal femur fractures. Issues of cut out and cut through phenomena related to technique were excluded. Expert opinion of 3 surgeons, each trained on several fixation systems at Level | trauma centers is reported.Data Extraction:Three authors extracted data using a predesigned form. Implant type, reported failure mechanism, and associated factors with implant failure were recorded as well as potential bias.Results:Of 2182 search results screened, 64 articles were deemed relevant for our research question and were included. The authors identified factors associated with implant failure: preoperative patient and fracture characteristics, intraoperative reduction, implant handling, and postoperative nonunion. Issues were identified as independent modifiable intraoperative risk factors: inadequate fracture reduction, varus position of femoral neck, direct damage of the cephalomedullary nail aperture by eccentric drilling related to guide sleeve handling, and implant design mechanism failures.Conclusions:Multiple factors associated with intraoperative handling can influence the healing of proximal femur fractures. Although many of these have been well described and are taught in fracture courses, surgeons should be aware of subtle intraoperative complications reported in the literature that can weaken implants and add to the likelihood of early failure.Level of Evidence: IV